BackgroundObstetric fistula affects a woman’s life physically, psychosocially, and economically. Although surgery can repair the physical damage of fistula, the devastating consequences that affect a woman’s quality of life may persist when she reintegrates into her community. This qualitative study assessed long-term outcomes among women who underwent obstetric fistula repair in Malawi. We explored three domains: overall quality of life before and after repair, fertility and pregnancy outcomes after repair, and understanding of fistula.MethodsIn-depth interviews were conducted in Chichewa with 20 women from seven districts across Central Malawi. All women were interviewed 1 to 2 years after surgical repair for obstetric fistula at the Fistula Care Centre in Lilongwe, Malawi. Interviews were independently coded and analyzed using content analysis.ResultsAbout half of women were married and nine of 20 women reported some degree of urinary incontinence. With the exception of relationship challenges, women’s concerns before and after repair were different. Additionally, repair had resolved many of the concerns women had before repair. However, challenges, both directly and indirectly related to fistula, persisted. Improvements in quality of life at the individual level included feelings of freedom, confidence and personal growth, and improved income-earning ability. Interpersonal quality of life improvements included improved relationships with family and friends, reduced stigma, and increased participation with their communities. Nearly half of women desired future pregnancies, but many were uncertain about their ability to bear children and feared additional pregnancies could cause fistula recurrence. Most women were well informed about fistula development but myths about witchcraft and fear of delivery were present. Nearly all women would recommend fistula repair to other women, and many were advocates in their communities.ConclusionsNearly all women believed their quality of life had improved at the individual and interpersonal levels since fistula repair, even among women who continued to have urinary incontinence. Contrary to other studies, women reported they were welcomed back by their communities and had limited challenges when reintegrating. Despite the overall improvements in quality of life, many continued to have relationship problems and were concerned about future fertility. These issues need to be further explored in other studies.

Introduction Women with vesicovaginal fistulas often experience a disruption in their normal lives, including sexual relationships, because of urinary incontinence. Aim Although surgery repairs the urinary leakage, it is not known how surgery might affect sexual function positively or negatively. Methods 119 women were enrolled before surgery and interviewed including a revised Female Sexual Distress Scale (FSDS-R) score and examined for vaginal length, caliber, and pelvic floor strength. Main Outcome Measures Approximately one third of women return to normal sexual function after repair, although a minority experience de novo dysfunction. Results 115 women completed follow-up 6 to 12 months after surgery. Approximately one third (35.6%, n = 41) stated that intercourse had returned to the way it was before a fistula. Forty-four women (40%) report sexual problems after the fistula developed; 15% due to incontinence and 23.5% due to pain. Fourteen women (12.2%) stated that they experienced problems with intercourse since surgery; 50% due to incontinence during intercourse and 50% due to pain. Nineteen of the participants (16.5%) scored in the range of dysfunction as assessed by the FSDS-R tool after surgery. Fibrosis did not significantly change and was not found to be associated with sexual function. Vaginal length was found to decrease on average by 5 mm. Of the variables examined, the factors statistically significantly associated with dysfunction included a larger-size fistula as determined by the Goh classification (> 3 cm diameter) and decreased vaginal caliber. FSDS-R scores drastically decreased from before to after surgery and the reason for problems with intercourse changed from leaking urine before surgery to lack of partner and concern for HIV infection. Clinical Implications Women with large fistulas and decreased vaginal calibers are at high risk for sexual dysfunction and should be counseled appropriately preoperatively and offered surgical and medical interventions. Strengths & Limitations Physical parameters were combined with qualitative interviews and FSDS-R scores to contextualize sexual health before and after surgery. Limitation is the brief follow-up of 6-12 months after surgery as many women were still abstaining from sexual activity. Conclusion Sexual dysfunction is a complex issue for women with obstetric fistulas; although many women do not continue to experience problems, several need ongoing counseling and treatment.

Aims: To report on the follow-up of obstetric fistula repair using vascularized surgical flaps, namely the Singapore fasciocutaneous flap, the gracilis muscle flap, or a combination of both.Methods: This cross-sectional study reports on the follow-up of 60 patients after fistula repair with a vascularized surgical flap at the Fistula Care Center in Lilongwe, Malawi. The primary outcome was fistula closure based on patients' self-reported continence grade. Secondary outcomes were urinary incontinence based on a 1-h pad-weight test, quality of life based on the Incontinence Quality of Life (I-QOL) questionnaire, surgical complications, and the indication for additional surgery after repair.Results: Successful closure was achieved in 62% of cases and full continence was achieved in 12% of cases. Incontinence based on a 1-h pad weight test improved between surgery and follow-up. QOL scores based on the I-QOL were low but patients indicated moderate to great improvement in quality of life. Twenty-two (37%) patients experienced surgical complication, mostly minor wound breakdowns. No major complications were reported. Six (10%) patients were indicated for additional surgery during follow-up. Conclusion:The relative safety of the surgical procedures is shown in the findings of this study, including no reports on major complications during follow-up. Vascularized flaps should be considered in complex fistula cases, especially in repeat cases and before considering urinary diversion as a last resort.

Objective: To measure depression over time using the Patient Health Questionnaire 9 (PHQ-9) and identify characteristics associated with persistent depression. Methods:A database of women undergoing obstetric fistula repair was used to examine associations between depression and variables such as demographics, type of fistula, and postoperative continence status. Results:A total of 797 patients completed the PHQ-9 at the initial preoperative assessment; 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating depression.Preoperatively, depression was associated with women aged 18-34 years, with no children, and with fistula for 5 years or less. Postoperatively, depression was associated with persistent incontinence. Over time, however, depression was rarely found among women returning for follow-up. Conclusion:Postoperative depression decreased over time in women who returned for follow-up, either due to selection bias or due to improved adjustment to one's circumstances. This study underscores the need for ongoing follow-up, especially for those not presenting for care or with persistent incontinence.

Aims: To measure depression using the PHQ-9 over time and to identify characteristics associated with persistent depression. Methods: A database of women undergoing obstetric fistula repair was used to examine association of depression with variables such as general demographics, type of obstetric fistula, surgical outcome, and continence status at the time of discharge. Results: 797 patients completed the PHQ-9 upon initial pre-operative assessment. 365 (45.8%) had a PHQ-9 score of 5 or higher, indicating symptoms of depression. Pre-operatively, depression was associated with the 18-34 year old age group and women with no children. Post-operatively, worse incontinence was associated with depression, however, over time depression was rarely found among women returning for follow-up. Conclusions: The decrease of depression seen over time is either due to selection bias or due to improved adjustment to one’s circumstances. Either way, this study underscores the need for ongoing follow-up, perhaps especially for those not presenting. Further studies are needed to assess the mental health of women who do not present for follow-up visits.